Jake Hoyne

🎉 Happy Match Day! We are THRILLED to welcome the newest members of the BIDMC Emergency Medicine family. Your hard work brought you here, and we can’t wait to train you and care for patients alongside you. Welcome to Boston and welcome to BIDMCEM! #MatchDay #EmergencyMedicine

@EM_phile Everything has a threshold, but doubt 65 is a magical number where 64 leads to worse outcomes. I think I just try to be reasonable.

They’re all probably close enough that they’re clinically the same. But to be pedantic, I’m not sure.

General curiosity: When you’re communicating MAP goals in a generic hypotensive septic pt to the team, what do you specifically say? Something like:

@EM_phile @nickmmark @mdonnino @Moskowcrit @reverendofdoubt @PulmCrit @IM_Crit_ I usually say something like "goal MAP around 65". These are realistically all the same thing though - eg, if the MAP is 60 and they're doing okay, I wouldn't necessarily push higher. If the MAP was 70 I wouldn't necessarily lower the pressors either.

@nickmmark @mdonnino @Moskowcrit @reverendofdoubt @PulmCrit @IM_Crit_ @JakeHoyne

@jwatson54 @ercowboy @PulmCrit Agree keep it simple. I prefer ket/roc for most. Some marginal benefits without significant downsides (eg analgesic, longer acting). Don't think this study tells us to avoid ketamine. I also think etom and/or sux is fine too. No singular correct approach.

@ercowboy @PulmCrit Agreed! It’s not like we’re using infusions of it… Ditto succinylcholine.. very very few situations where it’s actually not a great idea. Simplifying decision keeps things safe, I think

Dammit Farkas we’re WELL into Poe’s Law territory and have been for years on this decaying web site, cut the crap already and tell me if ketamine induction for sepsis is now a never event how i gotta be the one to tell you this

🔥 TCT Late Breaker in @JACCJournals: Are you ready for STEMI (OMI) networks 2.0? Queen of Hearts #AI reduces false activations by 5-fold while increasing sensitivity using only initial #ECG at triage!

@EMHighAK @drjgutt @SkylerLentz @sreeja_natesan @MikePallaci @davidcarr333 @PulmCrit @EMinMiami @Dane_o_MD @rob_cosentini @petrosoniak @skobner @AaronLacyMD @MRamzyDO @reverendofdoubt @pulmtoilet @EMCases Avoid the tachy-bolus reflex. Many patients are in RVR because they are volume overloaded and need diuresis, not an emperic bolus just because they're tachycardic. Find the underlying cause and treat it.

Afib w RVR — pearls/pitfalls? #FOAMed #MedTwitter @drjgutt @SkylerLentz @sreeja_natesan @MikePallaci @davidcarr333 @PulmCrit @EMinMiami @Dane_o_MD @rob_cosentini @petrosoniak @skobner @AaronLacyMD @MRamzyDO @reverendofdoubt @pulmtoilet @EMCases

@olsonplanner Does this mean they will actually process applications? I tried to switch to IBR in December and it's still in process.

What SAVE Borrowers Need to Know •Interest will resume August 1, 2025. It will not be charged retroactively. •Once the forbearance ends, borrowers will owe regular monthly payments including newly accruing interest. •Borrowers in SAVE: - Must switch to a different repayment plan (such as Income-Based Repayment) to resume making qualifying payments, including those seeking loan forgiveness through programs like Public Service Loan Forgiveness. - Can use the Department’s Loan Simulator to compare repayment options. - Do not need to submit a new IDR application if they already chose another plan like PAYE or ICR.

@Rick_Pescatore Had a colleague do a precordial thump on a sleeping patient with artifact on the monitor

one time when I was an intern I started cpr on a guy who was just sleeping so

@reverendofdoubt In terms of time to cath, I'm not surprised. I have sent patients to cath lab in the community without cardiology ever seeing the ECG. They called and said "if you think it's real, I trust you" and that was that.

Non-teaching hospitals performed better than teaching hospitals in the primary presentation of STEMIs... is anyone actually surprised by this data?

We are SO excited to announce our incoming intern class! 🎉 We’re so happy to welcome you to the BIDMC family! #happymatchday #emergencymedicine

@embasic @DrCasteelEM @jasonryanmd Just like medical school doesn't prepare you to be an amazing doctor on day 1, residency only trains you to be a novice attending and there is so much more to see and learn after graduation. You get the foundational skils and the way to think and adapt in real time.

@DrCasteelEM @jasonryanmd Almost 13 years out from residency and this is still true

Lots of medical students will match into specialties next week without having seen many of the common conditions of their chosen field. This is completely normal. I didn’t see a single case of CHF or septic shock in medical school. It had zero impact on my ability to function as an intern.

@olsonplanner Not sure if you know details on this or not, but I submitted an application to switch from SAVE to IBR in December that is still pending. I'm guessing everything is just in purgatory still?

IDR apps are closed. IDR income recertification apps are closed. For the next 3 months, with the caveat that this freeze could be extended or it could be cut short. - If you’re on an IDR, keeping PAYING. - If you’re told you’re up for income recertification, you just can’t right now. I don’t know if they’ll kick you off your IDR simply because you didn’t recertify (because you couldn’t!) or if they’ll just let it ride for awhile. - if you’re hoping to get on an IDR this May/June because you’re graduating med school, keep in mind that normally you get a 6 month grace period anyway. So you have until mid November to let this situation get sorted out longer than just the next 3-4 months. Anxieties are understandably high. There are some good residency loan options for you, like @LaurelRoad, should you be inclined to dispense with PSLF for good. $100/month payments last time I checked. Believe me - a loan repayment plan without PSLF is very feasible for most docs.

🧵 EM In-Service Exam: Departing thoughts—Top Tips for Residents 🚨 1/ This is my last year as an academic attending, so here’s a thread on how to crush the EM In-Service Exam and, more importantly, how to actually learn EM for real-world practice. Let’s go:

@reverendofdoubt We don't keep NPO here. Any amount of caffeine is a no-go though, even decaf drinks or hot chocolate

Is there high quality evidence to support “NPO after midnight” for a chemical stress test?

@reverendofdoubt I've had cases where a patient with ARDS got much more hypoxic because they were taken off the vent unnecessarily to get bagged, and it takes a long time to fix. I get it if it's an emergency (and I do it too), but most of the time you have a few minutes to systematically debug.

@JakeHoyne Agreed completely, and the last point is SUPER IMPORTANT

Hmmm… you’re never going to be smarter than the vent… usually disconnecting is the LAST thing I do in my algorithm as a last ditch effort. Thoughts from others?

@reverendofdoubt @EM_phile @mdonnino I agree! Nothing really earth shattering, but a nice summary of some of the literature. Still on team HAVL, Ketamine, & Roc most of the time. FWIW - I don't necessarily find "consider" to be the most helpful term and wouldn't hate if they would just "recommend" certain measures.

@EM_phile @mdonnino @JakeHoyne I missed this somehow! I *just* quickly skimmed the sections of interest to me. I think the recommendations are reasonable. Quick adoption of the PREOXI Trial. I think they did a good job interpreting the bougie literature, which also aligns with my interpretations.

Anyone have thoughts about this? acep.org/siteassets/sit… @mdonnino @reverendofdoubt @JakeHoyne

@reverendofdoubt @LWestafer Shocking the number of people who are only on albuterol despite guidelines changing years ago. The issue I frequently run into is insurance coverage of the combo inhalers is terrible.

@LWestafer I’ve been doing this (combined LABA/ICS + SABA) since I was an intern in 2019 since the GINA guidelines have been recommending this for quite a while

You routinely ensuring your patients in the ED with asthma exacerbations have an ICS? It's time we get on board acepnow.com/article/inhale…

@sargsyanz I think the best safeguard is to work in an environment where nursing is empowered to ask questions about orders they don't understand

Placing orders in the wrong chart is common. Have you seen/done it? Have you ever seen any safeguards? That didn't quickly become ineffective and infuriating? Any other strategies to avoid, either on a personal or systems level?

@reverendofdoubt @Wiki_Guidelines Was happy to see them call out first gen cephalosporins as a recommended option for cystitis and pyelo. #TeamKeflex

This is a pretty incredible @Wiki_Guidelines on UTIs. Wow—a must-read!!! It's interesting that "male" is no longer defined as a 'complicated UTI'! #full-text-tab" target="_blank" rel="nofollow noopener">jamanetwork.com/journals/jaman…